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Fill Your Texas 3703 Form

The Texas 3703 form, officially known as the Application for Plan Review for a Nursing Facility, is a document used to apply for plan review services for nursing facilities. This application is specifically for the Texas Department of Aging and Disability Services (DADS) and is essential for ensuring compliance with state regulations. To proceed with your application, please fill out the form by clicking the button below.

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Dos and Don'ts

When filling out the Texas 3703 form, it’s important to follow certain guidelines to ensure a smooth process. Here’s a list of things you should and shouldn’t do.

  • Do provide accurate facility information, including the full name and physical address.
  • Do include complete contact details for the facility/project contact person.
  • Do specify the type of application clearly by checking all relevant boxes.
  • Do ensure that all required fees are calculated and included with the application.
  • Don’t leave any sections blank; incomplete forms can lead to delays.
  • Don’t submit the application without reviewing it for accuracy.
  • Don’t forget to provide the remitter’s name and check number on the fee check.
  • Don’t assume that previous submissions are automatically included; always provide current information.

Sample - Texas 3703 Form

Application for Plan Review

for a Nursing Facility

Form 3703

September 2014

Service Code

324200100

LTC Review Fees

1.Facility/Project Information

Facility Name

Physical Address — Street

City

 

 

 

State

ZIP

 

County

 

 

 

 

 

 

 

 

 

Facility/Project Contact Person

 

 

 

 

 

Contact Person’s Title

 

 

 

 

 

 

 

 

 

Facility/Project Contact Person’s Telephone Number

Fax Number

 

 

 

Internet Address

 

 

(

)

(

)

 

 

 

 

 

 

 

Mailing Address (if different from physical address) — Street or P.O. Box

City

 

 

 

State

 

ZIP

 

 

 

 

 

 

Project Cost Estimate

 

 

Is the facility to be completely fire sprinklered?

$

 

 

 

Yes

No

 

 

2. Applicant Information

 

 

 

 

 

 

 

 

 

Owner or Owner’s Contact Person

 

 

Title

 

 

 

Telephone Number

 

 

 

 

 

 

(

)

 

Internet Address

 

 

 

 

 

 

Fax Number

 

 

 

 

 

 

(

)

 

Address (if different than facility)

 

 

City

 

 

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

Architect Firm

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

(

)

 

Name of Architect

 

 

 

 

 

 

Texas Registration Number

 

 

 

 

 

 

 

 

 

 

Project Manager

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

Internet Address

 

 

 

 

 

 

Fax Number

 

 

 

 

 

 

(

)

 

Mailing Address

 

 

City

 

 

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

Engineering Firm

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

(

)

 

Name of Engineer

 

 

 

 

 

 

Texas Registration Number

 

 

 

 

 

 

 

 

 

 

Project Manager

 

 

 

 

 

 

Title

 

 

 

 

 

 

 

 

 

 

Internet Address

 

 

 

 

 

 

Fax Number

 

 

 

 

 

 

(

)

 

Mailing Address

 

 

City

 

 

 

State

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

3. Type of Application (check all that apply)

Initial — New Construction

Initial — Relocation (New Construction)

Addition of Wing/Building/Area

Describe:

Laundry Kitchen Living/Dining Other:

Other details/description:

No. of Beds:

 

(for fee purposes)

Number of beds before project:

Number of beds after project:

Have plans been previously submitted for this project?

Yes No

If Yes, when?

By whom?

4. Type of Facility (check all that apply)

Single-story

Multi-story; Total no. of floors:

Alzheimer’s Certified

Capacity: beds

Locked Area NOT Alzheimer’s Certified Describe:

Capacity: beds

5. Fees

Fee Enclosed (see Texas Administrative Code [TAC], Title 40, Pt. 1, Ch. 19, §19.219) Remitter Name (who signed check)

$

Check Number:

Telephone Number

()

Instructions for Completing Form 3703

Application for Plan Review for a Nursing Facility

PROCEDURE

Complete this form to apply for optional plan review services for a nursing facility.

Note: This application is for a plan review by the Texas Department of Aging and Disability Services (DADS). A separate application is required for licensure. This plan review does not satisfy the requirements for a plan review by the Texas Department of Licensing and Regulation (TDLR) for accessibility.

Mail attached payment coupon with fee to:

Texas Department of Aging and Disability Services

Regulatory Services

P.O. Box 149055, Mail Code E-411

Austin, TX 78714-9055

Submit application and plans to:

Texas Department of Aging and Disability Services

Phone: 512-438-2371

Long Term Care Regulatory

Fax: 512-438-4623

Architectural Unit

 

Facility Enrollment, Mail Code E-250

 

701 West 51st Street

 

Austin, TX 78751

 

 

 

1.Facility/Project Information

Facility Name — Enter the full name of the facility.

Physical Address — Enter the address of the facility, including the city, state, ZIP code and county where the facility is physically located.

Facility/Project Contact Person — Full name of the person in charge of the building project.

Contact Person’s Title — Provide the facility/project contact person’s title.

Facility/Project Contact Person’s Telephone Number — Provide the telephone number, including area code.

Fax Number — Provide the facility/project contact person’s fax number, including area code.

Internet Address — Provide the Internet address or email address of the facility/project contact person.

Mailing Address — Provide the facility/project contact person’s mailing address, including city, state and ZIP code (if different from the physical address).

Project Cost Estimate — Provide the estimated cost of the project in dollars.

Is the facility to be completely fire sprinklered? — Check Yes or No.

2.Applicant Information

Owner or Owner’s Contact Person — Provide the full name of the owner’s representative.

Title — Provide the title of the owner’s representative.

Telephone Number — Provide the owner’s representative’s telephone number, including area code.

Internet Address — Provide the Internet address or email address of the owner’s representative.

Fax Number — Provide the owner’s representative’s fax number, including area code.

Address — Provide the address for the owner’s representative, including city, state and ZIP code (if different from the facility address).

Architect Firm — Provide the name of the firm or individual who produced the construction documents.

Telephone Number — Provide the architectural firm’s telephone number, including area code.

Name of Architect — Provide the full name of the architect whose seal is affixed to the drawings.

Texas Registration Number — Provide the architect’s registration number with the Texas Board of Architectural Examiners.

Project Manager — Provide the full name of the architectural project manager in charge of the project.

Title — Provide the architectural project manager’s title.

Internet Address — Provide the Internet address or email address of the architect in charge of the project.

Fax Number — Provide the architect’s fax number, including area code.

Mailing Address — Provide the mailing address, including city, state and ZIP code, of the architect in charge of the project.

Engineering Firm — Provide the full name of the firm or individual who produced the construction documents.

Telephone Number — Provide the engineering firm’s telephone number, including area code.

Form 3703 — Instructions

Page 2/09-2014

Name of Engineer — Provide the full name of the engineer whose seal is affixed to the drawings.

Texas Registration Number — Provide the engineer’s Texas registration number with the Texas Board of Professional Engineers.

Project Manager — Provide the full name of the engineering project manager in charge of the project.

Title — Provide the engineering project manager’s title.

Internet Address — Provide the Internet address or email address of the engineer in charge of the project.

Fax Number — Provide the engineer’s fax number, including area code.

Mailing Address — Provide the mailing address, including city, state and ZIP code, of the engineer in charge of the project.

3.Type of Application

Check the appropriate boxes for the type of application being submitted.

“Initial” means new facility or the conversion of an existing building into a licensed facility.

“Initial — Relocation” means relocating an existing licensed facility.

“Addition of Wing/Building/Area” means making an addition to a licensed facility.

Provide a one-sentence description of the addition.

“Laundry” means construction of a new laundry or renovation of or addition to an existing laundry in a licensed facility.

“Kitchen” means construction of a new kitchen or renovation of or addition to an existing kitchen in a licensed facility.

“Living/Dining” means construction of new living or dining space or renovation of or addition to an existing dining or living space in a licensed facility.

Check the box for Other and enter a brief description of other items included in the project.

No. of Beds — Provide the number of proposed beds for this project (for calculation of the plan review fee).

Number of beds before project — Provide the licensed capacity (number of beds) before this project.

Number of beds after project — Provide the proposed licensed capacity (number of beds) after this project.

Have plans been previously submitted for this project? — Check Yes or No.

If Yes, provide the date of last submittal and the remitter’s name.

4.Type of Facility

Check the appropriate boxes for the type of facility being submitted.

“Single-story” means a building with one floor level at grade.

“Multi-story” means a building with two or more floor levels, including basements.

“Alzheimer’s Certified” means a building, unit or wing that is certified to meet the requirements of 40 TAC §19.2208, Standards for Certified Alzheimer’s Facilities.

Capacity — Provide the number of beds in the existing or proposed Alzheimer’s certified facility, unit or wing.

“Locked Area NOT Alzheimer’s Certified” means a building, unit or wing that is locked for the protection of the residents.

Describe the locked area.

Capacity — Provide the number of beds in the existing or proposed locked area.

5.Fees

Compute the fee from 40 TAC §19.219.

Check Number — Provide the check number from the fee check.

Remitter Name — Provide the full name of the person whose signature is on the fee check.

Telephone Number — Provide the remitter’s telephone number, including area code.

§19.219 Plan Review Fees

(a)The Texas Department of Human Services (DHS) charges a fee to review plans for new buildings, additions, conversion of buildings not licensed by DHS, or remodeling of existing licensed facilities.

(b)The fee schedule follows:

(1)Facilities – new construction:

(A)single-story facilities — $20 per bed, $2,000 minimum; and

(B)multiple-story facilities — $24 per bed, $2,500 minimum.

(2)Additions or remodeling of existing licensed facilities — 2% of construction cost with $500 minimum fee and a maximum not to exceed $2,000.

(3)Alzheimer's certification — $550 in addition to the fees specified in paragraphs (1)-(2) of this subsection.

Payment Coupon for Facility Enrollment

Plan Review (324200100)

Facility Name and Address

Print Remitter’s Name (person signing check):

Make check or money order payable to:

Texas Department of Aging and Disability Services

Attach check or money order to this coupon and return to:

Texas Department of Aging and Disability Services

Regulatory Services

P.O. Box 149055, Mail Code E-411

Austin, TX 78714-9055

More PDF Templates

Documents used along the form

The Texas 3703 form is essential for applying for plan review services for nursing facilities in Texas. Alongside this form, several other documents are commonly utilized to ensure compliance with state regulations and to facilitate the licensing process. Below is a list of related forms and documents that may be required.

  • Texas Application for Licensure: This form is necessary for obtaining a license to operate a nursing facility. It provides detailed information about the facility, including ownership, management, and operational plans.
  • Architectural Plans: These detailed drawings illustrate the proposed layout and design of the nursing facility. They must be submitted for review to ensure compliance with building codes and regulations.
  • Engineering Plans: Similar to architectural plans, these documents focus on the engineering aspects of the facility, including structural integrity, plumbing, and electrical systems.
  • Fire Safety Plan: This document outlines the fire safety measures in place at the facility. It is crucial for ensuring the safety of residents and staff and must comply with local fire codes.
  • Accessibility Compliance Documentation: This document verifies that the facility meets accessibility standards as outlined by the Americans with Disabilities Act (ADA). It is essential for ensuring that all areas of the facility are accessible to individuals with disabilities.
  • Staffing Plan: This plan details the staffing requirements for the nursing facility, including the number of staff members, their qualifications, and their roles in providing care to residents.
  • Emergency Preparedness Plan: This document outlines the procedures the facility will follow in case of emergencies, such as natural disasters or health crises. It is vital for ensuring the safety and well-being of residents.
  • Financial Viability Statement: This statement provides evidence of the financial stability of the facility, including projected revenue and expenses. It is necessary for demonstrating the facility's ability to operate effectively.
  • Inspection Reports: Previous inspection reports from regulatory bodies may be required to assess compliance with health and safety standards. These reports provide insight into the facility's operational history.

These documents work in conjunction with the Texas 3703 form to facilitate the application process for nursing facilities. Properly completing and submitting these forms is critical for compliance with state regulations and for ensuring the successful operation of the facility.

Common mistakes

Completing the Texas 3703 form can be a straightforward process, but many individuals encounter common pitfalls that can lead to delays or complications. One frequent mistake is failing to provide the full name of the facility in the Facility Name section. This detail is essential, as it ensures that the application is accurately associated with the correct entity.

Another common error involves omitting the physical address of the facility. Applicants often neglect to include the complete address, including city, state, ZIP code, and county. Missing this information can create confusion and may result in processing delays.

Many applicants also overlook the importance of including the contact person's title. This oversight can lead to miscommunication, as the title helps clarify the role of the individual responsible for the project. Additionally, failing to provide a valid telephone number and fax number can hinder communication between the Texas Department of Aging and Disability Services and the applicant.

When it comes to the Project Cost Estimate, some individuals either leave this section blank or provide an unrealistic estimate. Accurate cost estimates are crucial for determining the appropriate fees and ensuring compliance with regulations. Similarly, applicants sometimes forget to indicate whether the facility will be completely fire sprinklered, which is a critical safety consideration.

In the Applicant Information section, another common mistake is not providing the Texas registration numbers for the architect and engineer involved in the project. These registration numbers are necessary for verifying the credentials of the professionals responsible for the design and oversight of the facility.

Many applicants also fail to check the appropriate boxes under the Type of Application section. This can lead to confusion about the nature of the project, whether it is new construction, relocation, or an addition. Providing a brief description of the project is essential and should not be overlooked.

Another area where mistakes frequently occur is in the No. of Beds section. Applicants sometimes provide inconsistent numbers regarding the capacity before and after the project. It is vital to ensure that these figures align with the overall project goals and comply with state regulations.

In the Type of Facility section, applicants may neglect to specify whether the facility is single-story or multi-story. This classification is important for regulatory purposes and impacts the overall design and safety requirements. Additionally, failing to describe locked areas that are not Alzheimer’s certified can lead to compliance issues.

Lastly, when it comes to fees, applicants often forget to include the remitter name and check number on the payment coupon. This information is necessary for processing the payment and ensuring that the application is linked to the correct fee submission.

By being mindful of these common mistakes, applicants can enhance the likelihood of a smooth and efficient application process. Attention to detail is key when filling out the Texas 3703 form, and taking the time to review each section carefully can save time and prevent unnecessary complications.

Misconceptions

Misconceptions about the Texas 3703 form can lead to confusion during the application process. Below is a list of common misconceptions, along with explanations to clarify them.

  • The Texas 3703 form is for licensing purposes. This form is specifically for plan review services and does not fulfill licensing requirements.
  • Submitting the form guarantees approval. Completion of the form does not guarantee that the application will be approved. It must meet all regulatory standards.
  • Only new facilities need to use this form. The form is also applicable for existing facilities undergoing renovations or expansions.
  • All projects require a fire sprinkler system. The form asks whether the facility will be completely fire sprinklered, but it is not a requirement for all projects.
  • Fees are fixed and cannot vary. Fees are based on specific criteria, such as the number of beds and the type of facility, and may vary accordingly.
  • Plans must be submitted in person. Applications and plans can be submitted via mail or fax, as specified in the instructions.
  • Architects and engineers do not need to be licensed. Both the architect and engineer involved must hold valid Texas registration numbers.
  • Only one contact person is needed. Multiple contact persons can be listed, including representatives for the owner, architect, and engineer.
  • Previous submissions do not need to be mentioned. If plans have been submitted previously for the project, this must be indicated on the form.

Key takeaways

  • The Texas 3703 form is essential for applying for a plan review of a nursing facility. It must be completed accurately to ensure proper processing.

  • Provide detailed information about the facility, including its name, physical address, and contact person. This information helps the reviewing agency understand the project better.

  • Clearly indicate the type of application you are submitting. Options include new construction, relocation, or adding a wing. This classification is crucial for the review process.

  • Include the estimated project cost. This figure is necessary for calculating applicable fees and ensuring compliance with state regulations.

  • Check whether the facility will be fully fire sprinklered. This information is important for safety assessments and compliance with fire codes.

  • Make sure to submit the application and plans to the correct address. Use the Texas Department of Aging and Disability Services to avoid delays.

  • Understand the fee structure outlined in the form. Fees vary based on the type of facility and the scope of the project, so calculate them carefully to avoid issues.

File Characteristics

Fact Name Details
Form Title Application for Plan Review for a Nursing Facility Form 3703
Version Date September 2014
Service Code 324200100
LTC Review Fees Fees vary based on the type of construction and facility size, as outlined in Texas Administrative Code (TAC), Title 40, Pt. 1, Ch. 19, §19.219.
Applicant Requirements The applicant must provide detailed information about the facility, including contact details and project estimates.
Fire Sprinkler Requirement The application includes a question on whether the facility will be completely fire sprinklered.
Types of Applications Options include Initial New Construction, Initial Relocation, and Addition of Wing/Building/Area.
Facility Types Facilities can be categorized as Single-story, Multi-story, or Alzheimer’s Certified.
Fee Calculation Fees are calculated based on the number of beds and the type of construction, with minimum and maximum limits specified.
Submission Process Applications and plans must be submitted to the Texas Department of Aging and Disability Services at the specified address.

How to Use Texas 3703

Filling out the Texas 3703 form is an important step in the application process for nursing facility plan reviews. This form collects essential information about your facility and the project at hand. Make sure you have all necessary details ready to ensure a smooth completion.

  1. Facility/Project Information:
    • Enter the full name of the facility.
    • Provide the physical address, including street, city, state, ZIP code, and county.
    • List the full name of the contact person for the project.
    • Include the contact person's title.
    • Provide the contact person's telephone number and fax number.
    • Enter the internet address or email of the contact person.
    • If the mailing address is different from the physical address, provide it here.
    • Estimate the project cost in dollars.
    • Indicate whether the facility will be completely fire sprinklered by checking Yes or No.
  2. Applicant Information:
    • Provide the full name of the owner or owner's contact person.
    • Include the title of the owner’s representative.
    • List the owner's representative's telephone number and internet address.
    • Provide the fax number for the owner’s representative.
    • If different from the facility address, include the address of the owner’s representative.
    • Enter the name of the architect firm and their telephone number.
    • List the name of the architect and their Texas registration number.
    • Provide the name and title of the architectural project manager.
    • Include the internet address, fax number, and mailing address for the architect.
    • Repeat similar steps for the engineering firm, including the engineer's name and Texas registration number.
  3. Type of Application:
    • Check all applicable boxes for the type of application: Initial, Relocation, or Addition.
    • Provide a brief description of the addition if applicable.
    • Indicate the number of beds for fee purposes.
    • State the number of beds before and after the project.
    • Indicate if plans have been previously submitted for this project by checking Yes or No.
    • If Yes, provide the date and remitter's name.
  4. Type of Facility:
    • Check the appropriate boxes for the type of facility: Single-story or Multi-story.
    • Indicate if the facility is Alzheimer’s Certified and provide the capacity.
    • Describe any locked areas that are not Alzheimer’s Certified and provide their capacity.
  5. Fees:
    • Compute the fee based on the Texas Administrative Code.
    • Provide the check number and the name of the person who signed the check.
    • Include the remitter's telephone number.

Once you have completed the form, mail it along with the payment coupon and fee to the Texas Department of Aging and Disability Services. Ensure all information is accurate to avoid delays in processing your application.